Table 4

Summary of included papers

Paper details		Extraction
Author, year and origin	Journal and type of paper	Method and aim of study	Factors influencing retention	Efforts to improve retention	Other relevant findings
Estryn-Behar et al.,48 2011, France	Emergency Medicine Journal, research paper	Questionnaire using several psychological scales applied to 538 EPs and 1924 matched physicians from other specialties, aimed to measure and correlate aspects of working life and intention to leave.	Intention to leave linked with quality of teamwork, burnout, musculoskeletal disorders, job offers from outside medicine, absence of continuing education for 12 months, worry about mistakes, harassment by superiors, lack of influence at work and tense relations with administration.	None.	Working conditions may be more important than pay.
Feitosa-Filho et al.,49 2017, Brazil	Revista da Associação Médica Brasileira, research paper	Questionnaire of 659 ED physicians across a region of Brazil assessing workplace characteristics, EPs training, main reason for working in EM, work satisfaction and reasons why they might leave; primary aim to quantify work characteristics.	Higher job satisfaction correlated with lower intention to quit.	None.	81.3% said they intended to stop working at the ED in the next 15 years, pointing out ‘excessive stress at work’ as their main reason.
Fitzgerald et al.,40 2017, UK	Emergency Medicine Journal, research paper	Interpretive phenomenological analysis study based on 18 semistructured interviews with EM consultants in southwest England, primary aim to explore the experience of psychological distress and well-being.	Consultants perceive the physical and emotional strain of EM work to be unsustainable, peer social support and developing new roles can help sustainability.	The emergence of self-care and compassion dialogues may be beneficial.	Participants unanimously identified with the term ‘sustainability’ when describing their emotional and physical status.
Goldberg et al.,45 1996, USA	Academic Emergency Medicine, research paper	Questionnaire of 1272 attendees at an EM conference over 4 years; questionnaire incorporated the Maslach Burnout Inventory and practice demographics, including intent to practice EM in the future, aiming to measure burnout and to identify predictive factors.	Intention to leave EM correlates with a higher burnout score.	None.	None.
Hall et al.,33 1992, USA	Academic Emergency Medicine, research paper	Postal questionnaire sent to US EPs who finished training between 1978 and 1982; 539 responses; compared practice characteristics of those who still practice EM with those who have left.	Those who left were less likely to be board certified in EM, more likely to be board certified in another specialty, were less likely to work with residents and reported lower income.	None.	None.
Hall and Wakeman,361999, USA	The Journal of Emergency Medicine, research paper	Questionnaire sent to residency trained EPs about demographics, work characteristics, attrition and reasons for leaving. 1638 responses. Aims to measure practice characteristics, how careers change with time and career longevity.	EPs with higher income had lower attrition, but those who left did not rate income as a reason for leaving. EPs who had done a residency or fellowship outside EM or were not board certified had higher attrition.	None.	Clinicians decreased clinical work and increased other work though their career.
Holmes,47 2019, Australia	Emergency Medicine Australasia, brief communication	Discussion paper (termed ‘Perspective’ in this journal) giving the authors view on sustainable careers in EM is Australia. Two areas of focus are burnout and the ageing EP.	The author believes that credentialing in a subspecialty field, maintaining professional links and lifelong learning may help sustainability.	Unreferenced claim that some countries do not require older doctors to work on-calls or out of hours and a belief that this would help in Australia.	The authors state that 'there has been insufficient recognition of the particular needs of older physicians, including that they tolerate shift work and night duty more poorly than their junior colleagues.'
James and Gerrard,39 2017, UK	Emergency Medicine Journal, research paper	Semistructured interviews with 10 consultants from Welsh EDs exploring what attracted them to the career and what keeps them there.	Diagnostic challenges, teaching junior colleagues, teamwork, flattened hierarchy, flexible working and positive work–life balance.	Participants thought that improving flow and staffing would help retention.	None.
Kalynych,41 2010, USA	UNF Graduate Theses and Dissertations, dissertation, primary research	Questionnaire of 273 EM residents measuring margin in life (psychological theory of adult development) scale and intention to leave; aim to assess for a difference between EM residents scores and remediation, intention to quit and actual attrition.	No correlations identified.	None.	None.
Lloyd et al.,35 1998, Canada	Academic Emergency Medicine, research paper	Questionnaire to compare two different job satisfaction instruments with 14 'reasons for leaving'. The study aim was to evaluate the predictive validity of the Emergency Physician Job Satisfaction and Global Job Satisfaction instruments.	A low Global Job Satisfaction instrument score is associated with leaving EM (the test characteristics mean it is not a useful predictor).	Scheduling, as an extrinsic component of job satisfaction, is amenable to change.	Ranked reasons for leaving EM and compared with a previous (US) cohort.
Mallon,44 2000, USA	The Journal of Emergency Medicine, letter	Letter commenting on Hall and Wakeman 1999 and referencing the authors’ study (Goldberg et al.45)	Reiterates key points from Goldberg et al.45	None.	Concern about overestimating attrition and oversubscribing the workforce devaluing EPs and creating job insecurity.
Murphy,46 2014, Ireland	Irish Medical Journal, editorial	Editorial outlining the retention problem in Ireland.	Better support and less stress, personal development.	Streamline training, ministerial review of the medical workforce.	There is a retention problem across Irish medicine; it is more visible in EM.
Pflipsen et al.,37 2019, Ireland	Irish Journal of Medical Science, research paper	Questionnaire sent to those who had left the Irish EM training scheme. 30 respondents, aim to gain insight into reasons for attrition from EM training in Ireland	Lack of training and supervision negatively impacted retention, as do excessive workloads and poor working conditions.	None.	Findings similar in other specialties in Ireland.
Smith and Dasan,42 2018, UK	British Journal of Hospital Medicine (London),review	Pragmatic review of academic and policy literature aiming to describe the impact increasing working pressure is having on staff in the ED and to begin to explore the potential for developing sustainability within the workforce.	Occupational stress and burnout negatively impact retention.	Job planning, less than full time working, portfolio careers, appropriate renumeration, well-being; introduces sustainability work from Royal College of Emergency Medicine.	None.
Takakuwa et al.,50 2013, USA	Academic Medicine, research paper	Questionnaire sent to leads of EM training programmes, 78 responses, aims to describe the policies, practices and attitudes of EM leaders about workforce issues, particularly for EPs in the last decade of their career.	A strategic approach to staffing overnight shifts, various different policies inconsistently applied.	Refers to documents related to ageing and EM work produced by the group that did this research.	Variable and inconsistent approach to the role of the EP in the final 10–15 years of their career.
Xu et al.,34 1994, USA	Academic Emergency Medicine, research paper	Cohort Study using routinely collected data; looking at three groups: those who choose EM and stay, those who move into EM and those who leave; compares academic performance, age and indebtedness with an aim to identify factors that may have contributed to career change.	High academic performance and high indebtedness are factors associated with choosing or staying in EM.	None.	Indebtedness is complex.
Xu and Veloski,38 1991, USA	Academic Medicine, brief communication	Questionnaire sent to graduates of a specific university who had chosen EM at graduation, 36 responses, aim to measure factors influencing their decision to continue EM careers.	Most important factors for remaining in EM were challenging diagnostic problems, predictable working hours, intellectual content of the specialty and income.	None.	Educational debt a minor factor.
Zun et al.,43 1988, USA	American Journal of Emergency Medicine, discussion	Case report and literature review. Describes a case where a patient dies after being discharged from the ED. This leads to a discussion, citing relevant literature, about the stress such an event causes and stress for EPs in general.	Discusses factors that lead to stress for EPs, specifically errors, incivility by colleagues and working patterns.	Authors’ thoughts; open discussion as key to helping manage stress, also helped by time management systems, lifestyle approaches and specific relaxation approaches.	None.

EP, emergency physician.